Provider Demographics
NPI:1225283088
Name:DESALVO, MICHELLE LUCIA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LUCIA
Last Name:DESALVO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:SIMANCAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 66308
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77266-6308
Mailing Address - Country:US
Mailing Address - Phone:832-548-5000
Mailing Address - Fax:
Practice Address - Street 1:5602 LYONS AVE
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77020-4721
Practice Address - Country:US
Practice Address - Phone:832-548-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-20
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA030556363A00000X
TXPA05697363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant